National Health Service: R&D

§Lord Hunter of Newington rose to call attention to the importance of research and development for the future of the National Health Service; and to move for Papers.

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The noble Lord said: My Lords, major reforms were embedded in the National Health Service Act 1990. At the same time, the Government accepted the substance of the House of Lords Select Committee report on research in the National Health Service and decided to appoint a director of research and development and that he should be a member of the NHS management board. I am sorry that the noble Lord, Lord Nelson of Stafford, is not here today. As chairman of the Select Committee he has achieved a great deal and the success, I believe, is substantially due to him.

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It is my intention to argue the case that the new research and advisory machinery introduced by the director should produce the information for change and also information about the cost of procedures. I have spoken to a number of consultants in different parts of the country and I do not think there is any doubt that he has stimulated them enormously and they are looking forward eagerly to participating in the schemes which are now being formulated.

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There is no mention in the reforms that implies rationing of care, yet many are worried that we cannot continue to provide resources to meet health needs. Some of our health economists are thinking about these matters and the whole question of consensus rationing is being considered. I shall mention this again later.

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At present authorities make decisions about the allocation of resources to different categories of care. Doctors decide about allocation to individual patients taking into account their detailed personal and medical circumstances. The size of the waiting list may mean that resources are not immediately available. The nature of the waiting list will be an important signal as long as this facility is available. If it is not available, the demand for adequate resources will be immediate.

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Among the important challenges for the future there are two serious conditions that occur frequently. One is heart and vascular disease, the other cancer. Both have been linked to diet and personal habits, so much so that we are now urged to eat healthy foods and conduct our life-style in healthy ways.

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Formidable problems have existed over past years and many of the specific causes of diseases have been discovered. When that has happened steps can be taken to treat or prevent the condition. One example is that we know that scurvy is due to a deficiency of vitamin C and that the first discovery of importance was that the juice of limes cured the condition. But the other factors supposed to contribute to the situation before this discovery bear a remarkable resemblance to today's cancer list. Here are some examples: diet, depression, infection, tobacco, damp, constitutional heredity and poor environment. All had supporters but scurvy was due only and entirely to a vitamin deficiency. That must constitute an important lesson for other fields such as the cancer field.

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Inevitably, cancer and heart disease will present themselves as a challenge to the director and his staff. There are, of course, proven causes of cancer such as smoking and various chemicals, but what of the cancers thought to be associated with food intake? Overall there is insufficient evidence to recommend reducing fat or food consumption with the aim of reducing the risk of cancer. Yet the nature of cancer varies in different parts of the world where there are different lifestyles and environments.

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The results of various investigations have suggested that a range of dietary measures have an impact on cancer, but the evidence of these factors is not conclusive enough to warrant recommendation. This is the view of the Royal College of Physicians. However, Sir Richard Doll in his book The Causes of Cancer links no less than one-third of cancers to diet.

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The analysis of statistics around the world reveals that the incidence of different cancers is different in different countries—for example, breast and colon cancers occur in western society and stomach cancers in Japan. This could suggest that the cause must lie in some difference between societies, the most obvious of which is diet. The temptation has become overwhelming, and has spread rapidly in some sections of the medical profession, to suggest that food causes cancer and therefore the thing to do is to eat healthy food. The healthy food lobby has taken off and it is now considered to be part of the "new public health".

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Attempts to treat vascular disease with diet, particularly through the control of sodium intake and low cholesterol diets, have not been very successful. To confirm that view one needs only to read the weekend's newspapers and last week's British Medical Journal. Certainly it is possible to reduce the salt to low levels with some alteration in blood pressure, but the consequences of this are uncertain. We also know that the cholesterol situation is more complicated from the biochemical point of view than was first thought. In contrast to this lack of progress in the treatment of vascular disease, remarkable progress has been made in the surgical treatment of vascular disease and this illustrates another important issue which faces the director of research and which requires monitoring and costing.

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Ten years ago surgery was considered to be of limited use in the treatment of coronary artery disease and it was thought that perhaps treatment should be confined to those under the age of 50. Now it is known that satisfactory results can be achieved in respect of people in their 70s with reasonable life prospects. There is other evidence also to support the idea that age is no longer a contradiction to major surgery.

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I wish to ask the Minister what machinery has existed in the past and whether it is suggested now to monitor situations where new or extended treatments are introduced, often at substantial costs. At least now it will be possible to have this kind of situation studied and to have the results of those studies placed before the management board and the health authorities. The situation can also be analysed from the point of view of the provider of equipment and accommodation. As I said, there is an increased awareness among staff at all levels as to the importance of these studies. I understand that the machinery to implement the studies will shortly be in place. The discovery and identification of treatments and their improvement is a vital part of an active dedicated service.

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I wish to return briefly to the question of consensus management and of resources. The essence of the reforms under the 1990 health Act is the separation of the functions of purchasing health care by health authorities from the provision of care by providers such as hospitals or others. The two are linked by contracts. This has shifted some of the power to prescribe how resources will be allocated from doctors and nurses in favour of managers and health authorities. At the same time it is recognised that only doctors and nurses acting as general managers can really manage the use of resources for patients. It is
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obvious that to achieve a successful and efficient running of the NHS there should be a willing partnership between professional activity and management.

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In 1972 I chaired a working party in the Department of Health which made recommendations about medical administrators in the NHS. Recommendations were made on how medical men could be retrained and how they could become involved in administrative matters. The response of the Government was to introduce a form of consensus management; at that stage it constituted an agreement between those providing the actual care. But for one reason or another this did not produce any real solution to the problem. I now believe this requires a two tier system with doctors represented at both levels. The system of providers and purchasers introduced by the Government in 1990 involves an element of financial control contributed to by managers and doctors at two levels. This does not go as far as the Oregon proposals in the United States which remove responsibilities from doctors and nurses by legislation and prevent treatment of certain categories of patients.

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Some people have linked the concept of consensus management with the idea of quality adjusted life years (QALY) as a basis for allocating resources not to patients but to the more cost-effective procedures. Such a procedure removes from the individual doctor the possibility of making decisions only in the interests of the patient. I believe that the use of quality adjusted life years as a means of allocating resources is wrong.

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From the early experience of the newly-introduced system under the 1990 Act, though there has been, as I have said, some shifting of power in the allocation of resources in favour of managers and health authorities this is relatively modest and I believe fully justified by the results. The medical profession does not object, as it undoubtedly would, to a number of other procedures that I have mentioned. The House would like to hear the Government's view on these matters, particularly on the matter of quality adjusted life years. My Lords, I beg to move for Papers.

My Lords, we all owe a great debt to the noble Lord, Lord Hunter of Newington, for starting a debate in the course of which I hope the sum total of speeches will provide useful guidance to the Central Research and Development Committee. I speak only too obviously as a layman but one who has become convinced over the years of the important doors which health research has already opened for the health profession. I am also aware of the handicaps under which doctors and those in other disciplines work while many doors still remain firmly shut.

Research has an obvious part to play—the noble Lord, Lord Hunter, has already made this clear—in the prevention of illness and injury, and still more in their acute treatment. It equally has a role to play in the subsequent attempt to restore function which illness or injury has impaired. Therefore I wish to speak about rehabilitation research, and for two main
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reasons. First, I believe it can provide benefits equal to those gained through research into prevention or acute treatment. Secondly, this area of research, having suffered much neglect, now shows some signs of improvement. The number of relevant research papers is growing. Contributors to them come from a wider range of disciplines. In addition, half the membership of the important Society for Research in Rehabilitation is non-medical. That is important because collaborative research between disciplines has a value which goes beyond its contribution to the total amount of knowledge.

The contribution itself is of enormous importance. It ranges from the urgent need which we all recognise to reduce costs, both human and financial, right through the social claim which disabled people rightly make to play a greater part in the nation's activities, to the potential transformation of quality of life by more enlightened methods of rehabilitation and the availability and affordability of complex technological equipment.

Only a few days ago I was discussing the vast toll, both in human suffering and economic loss, exacted by disorders (often barely tolerable) in the functioning of our backs. Sadly, that is only one example of hundreds of afflictions which cause misery to those who suffer and to those who care for them as well as imposing a growing burden of cost on the nation.

Among all the conflicting claims there is no escape from the difficult task of setting priorities, not only between the different stages of health care—prevention, treatment, rehabilitation—but also between a goodly number of competitors in rehabilitation research alone.

My noble friend will know that many ideas have been put before her right honourable friend and her honourable friends in her department by the neurological charities and many others in their response to The Health of the Nation. To a layman it is all too evident that the right ordering of priorities for research presents a real challenge.

In that connection, I look with some confidence and even more hope at the fairly young Central Research and Development Committee of which I spoke earlier. In particular, in the context of the field which I am discussing, I look to my friend Professor Lindsay McLellan, one of its distinguished members and a champion of the claims of disabled people. I shall be surprised and disappointed if he does not press strongly for research for their benefit to be lifted high on the council's agenda.

I hope—but this may merely reflect the natural inclination of a layman—that careful consideration will be given to those areas of research which include a clear practical content. Such research would include, for instance, projects which are directed towards developing a man or woman's capacity for employment; towards enabling more disabled people to remain in their own homes; towards the recruitment of more therapists (which is a very urgent need); towards widening the skill and expertise of carers who look after the disabled; and towards
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providing a new stimulus for those in a position to produce much needed equipment, both simple and sophisticated.

Recent developments and news of changed attitudes, at a variety of research levels and across a spectrum of different disciplines, give me some grounds for hope. I shall be greatly encouraged if my noble friend, when she replies, can assure me that my hopes are well founded. In particular, I hope that she can assure me that Her Majesty's Government will give enthusiastic backing to rehabilitation research and development both through the Central Research and Development Committee and through the department's own programme. I understand that several of that programme's themes to which the department has recently given priority (and I speak particularly of research into the development of community care) could be of deep significance to disabled people.

My Lords, I should like to thank my noble friend Lord Hunter for choosing this topic because it allows the House to reflect further on the work of the Select Committee of the House which looked into priorities in medical research with particular reference to the needs of the National Health Service.

Noble Lords will remember that the Select Committee's report was published in March 1988. The Government finally responded to that report some 18 months later in December 1989. However, they rejected our central proposal to create a National Health Service research authority independent of but linked to the Department of Health which could ask its own questions. Instead, as my noble friend said, the Government have created the post of Director of Research and Development, the holder of which has a seat on the National Health Service Management Executive. That was achieved after some pressure, particularly during Questions in this House.

From the programmes developed under the aegis of the new DRD, Professor Michael Peckham, as described in the Government's document Research for Health, which was published in September last year, it appears that the research programme for the National Health Service, which sounds very ambitious, will be under the general control of the Department of Health, however devolved to regions the conduct of that research may be. The plans set out in that document place much emphasis on the delegation of the research and development to the regions with the aim of increasing overall the percentage of expenditure on research and development to 1.5 per cent. of the total National Health Service budget over a five year period.

I find it very hard to believe that that is feasible given that the Select Committee found that the National Health Service spends only 0.2 per cent. of its budget on research and development at present, based on a sum of £40 million. That sum was stretched to £60 million by a report on research in the National Health Service by the Parliamentary Office of Science and Technology. That still does not bring the
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percentage to very much more than 0.2 per cent. of the budget, whereas figure 2 in the department's document estimates expenditure on research and development by the National Health Service and the Department of Health at £225 million in 1989–90—about 1 per cent. of the whole. I can only suggest that that larger sum has been arrived at because some of the items included in that figure are not strictly research activities and possibly not strictly funded by the National Health Service. Be that as it may, an increase to 1.5 per cent. over a five year period requires a major expansion of research activities, particularly if we take the present percentage to be 0.2 per cent. rather than 1 per cent. as suggested in the document.

I wonder whether the Government are not being a little unrealistic. Good research and development into the workings of the National Health Service cannot be achieved overnight. There are relatively few research workers who are experienced and competent in health services research because there are only a few centres of excellence in the country which attract staff of the right calibre and train them in the methodologies required.

An essential characteristic of health services research or public health medicine research is that, to be effective, it has to be a team effort. The team must be multi-disciplinary. For example, when inquiring into the reasons why patients behave as they do or use services in a certain way it is not sufficient for research to be designed or carried out by clinically trained doctors alone. There is also a need for input from behavioural scientists such as anthropologists, medical sociologists, psychologists as well as health economists, demographers and statisticians.

To build a team of such experts requires time and patience. The stability of the unit housing the team is important because each of the experts comes from a different home discipline. If they are not given security in their health services research unit they will tend to desert it and go back to the security of their own academic base. That is why the committee put emphasis on the creation and funding of research programmes lasting over a period of five to 10 years or more with a guaranteed core funding element rather than projects which are temporary and intended to answer specific questions.

For that reason I hope that the noble Baroness will be able to assure the House that programmes of research will be backed and not merely projects. The Select Committee felt that it was important to build on the three or four existing centres of excellence in health services research which could act as nuclei for the training of future researchers as well as administrators who would then have a real grasp of the dynamics of how health services operate. In the Government's document I do not see any recognition of the fact that health service research workers need to be trained.

In that document there is a directive that each region should appoint a director of research and development and that regional R&D plans should be published by September this year. I am worried that such plans may be put together hurriedly and without adequate reflection. Are there sufficient high caliber
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candidates to supply all the regions in such a short time? Academic units will have to be consulted when drawing up such plans. I very much hope that they will be consulted; otherwise, even more data may be collected—which is hard to conceive of—without any clear purpose. It will be called research rather than simply the collection of statistics.

Turning from what sounds a rather critical remark, I understand the need for information technology. Some of the information that has been collected about health service activities since the new Bill became an Act has been useful. But there is a lot of work involving data collection which we could do without. I have a feeling that if the target of 1.5 per cent. NHS expenditure is reached too hurriedly the money may not be well spent. At worst it may even detract from patient care rather than improve it because of a diversion of funds. There is an impression that some of the best academic units in public health medicine in primary care will still be struggling for survival when public funds may be spent on relatively low quality research in the regions to achieve regional research and development targets. I very much hope that I am wrong. I plead for full support and collaboration with the few centres of high quality health services research that exist. I mention no names. I could do so but that would be invidious at this stage.

I should like to ask the noble Baroness two questions. Does she know of any definitive research which has been commissioned to follow up the recent questions raised by the department's inquiries into health care needs? There were some five or six, including diabetes, stroke, hip replacement, renal problems, and so on. Many of us are critical of the Government's decision to press ahead with the NHS reforms in advance of any pilot studies. We were assured that the first wave of trusts or fund holders would be studied and would act as pilot schemes. Can the Minister tell us how the National Health Service changes are now being evaluated? Can she answer the criticism that the first wave candidates and the best organised and therefore most likely to be able to cope with the changes? Are the data which we are being given only those which reflect the credit side and not the debit side of the changes? For instance, how much money is being spent by certain fund holding general practices on private sector facilities, thus leaving the National Health Service with less money to fund its own provider units?

I have run out of time. I had intended to discuss health promotion and research to some extent. However, I know that my noble friend Lord Butterfield will cover that area and I leave it to him to do so.

My Lords, all noble Lords taking part in this debate will be aware that it was not originally my intention to speak. The noble Baroness, Lady Robson, who has considerable experience in the field of cancer research—her work for the Imperial Cancer Research Fund is well known —had intended to speak from these Benches. We felt that it was important to put forward a speaker. We
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attach enormous importance to research and development, particularly in the area which directly concerns patients and which is referred to as clinical research. On behalf of the noble Baroness, Lady Robson, and all of us on these Benches, I should like to thank the noble Lord, Lord Hunter of Newington, for giving us the opportunity to discuss this subject.

I understand from the notes which I hastily took from my noble friend, who knows much more about this subject than I do, that the taxpayer directly through the Medical Research Council funds research up to slightly more than £200 million a year. A similar sum comes from the voluntary sector. It appears that only about 25 per cent. of research funded through the Medical Research Council directly involves patients and the benefits to patients.

The three points that my noble friend wanted to raise come under the heading of clinical research: first, the optimum use of nursing resources; secondly, health needs in particular districts; and, thirdly, research into care of the elderly, a topic which touches many people like myself who are in the middle of middle age and lucky enough still to have an elderly parent.

My noble friend came across a quotation which is worth repeating. There is no doubt that a great deal of research which directly involves the patient takes place after the stage of development. It is rather putting the coach before the horses. For reasons which are perfectly well understood but widely criticised, the Government have sought to introduce changes in the way in which patients receive attention. They have changed the emphasis from care directly in the hospitals to care in the community. They have taken a business approach.

The Life and Times of Dr. Thomas Hodgkin is a book which describes an eminent physician who practised in what I might call Dickensian London. He did a lot of work for the poor in Guy's Hospital. He attacked the method of providing medical care for the destitute, in which he was much involved, whereby contracts were let for specified periods of time to the lowest bidder. He charged the arrangement with faulty assessment; namely, that business techniques could be used to obtain care at the most efficient price. He argued that in business the quality of the delivered product could be assessed and a determination could be made of whether the lowest bidder had delivered the object of the bid in an acceptable form. He stated that in medicine, however, the public had no adequate means of testing the comparative value of the advice offered or the amount of services rendered. I suggest that that point is as relevant today as it was in the days of Dickens.

To return to the three points that I wanted to cover in respect of clinical research, I pick up the issue of research into the best use of nursing resources. There is no doubt that there has been a great deal of discussion and experimentation in the substitution which has shown benefit to patients and considerable benefits in terms of cost reductions. The studies are all, no doubt, very valuable individually. However, perhaps in her reply to the debate, the Minister will be
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able to say whether there is a plan to gather comprehensively together all the results in order that the overall picture may be assessed.

We are talking about the balance between cost savings and the benefit for patients. There is the substitution of nursing staff for medical staff and nurse practitioners. There is also the substitution between nursing staff and other health service occupations and professions and the overlap in the community with social workers, and so on. It is an area in which a great deal is being done. However, a great deal needs to be done to collect the information in order that it may be acted upon where necessary.

The second point that my noble friend wished to touch upon is the health needs in particular districts. They are obvious if one walks through London. It is quite clear that as a result of the Government's policies with regard to taking people out of hospital and placing them in the community, there are many people who are not in the best of mental health. In such areas as Tower Hamlets an area which is characterised by a number of cheap hostels and a home run by the Salvation Army, there are a great number of people who are in need of a specific health service. That would not be the case in rural areas. Indeed, the health requirements in urban areas such as London, Manchester, Liverpool or Glasgow are clearly distinctly different, even to the layman, from those in less dense areas in terms of age difference if nothing else. Some areas have concentrations of elderly people. In others there is a greater number of young people.

My noble friend's third point is dear to my heart. I have an elderly mother who recently had an operation to replace a kneecap. When I brought my mother home from hospital it was quite clear that if I had not been able to arrange some very able, almost full-time, help in order to rehabilitate her over a number of weeks she would have had great difficulty. At that time I considered the position of some elderly people—conditions vary from area to area—who, after having excellent treatment in hospital, go straight back to their homes in which they will not have supervision for exercise or physiotherapy, let alone diet. How much research has been done in that area? How much research has been collated and disseminated?

I am sure that I have not done justice to the points that my noble friend wished to raise. However, I have at least made the point that clinical research is an issue in which we on these Benches are much interested and about which we are much concerned. As I said only the other day on another subject, as time goes by there will be more and more elderly people in our society. I believe that today a new magazine is published called the Oldie. Whether or not that publication will last for long is difficult to judge, but it emphasises that it is even to the forefront of journalists' minds that the balance of society is changing between old and young.

I conclude on that point. I look forward to the noble Baroness giving a reply which will make us optimistic about the changes that are taking place and the benefits that will come from them in the near future.

My Lords, I never ascend the steps of a pulpit, even in the smallest country parish, without a certain nervousness. My trepidation on this occasion can therefore be imagined.

I too am grateful to the noble Lord, Lord Hunter, for initiating a debate on this important subject. It is a cause for profound thanksgiving that advances in medical knowledge gained through research have led to the alleviation of a great deal of suffering. It is obviously right both to encourage that research and to honour those engaged in it. Equally, there is common consent that medical research should always be accompanied by reflection on the implications of the knowledge that is gained and, as a consequence, by regulations which control the use to which the knowledge is put.

Those matters were discussed in this House at length and with very great authority two years ago during the passage of the Human Fertilisation and Embryology Bill. It would be impertinent of me to think that I could in any way aspire to the wisdom and experience which were demonstrated on that occasion. But whenever questions concerning medical research are raised, I believe that it is right to remind ourselves of the need to pay close attention to the ethical issues which inevitably arise.

We are all aware that, as the frontiers of knowledge are extended, some of the possibilities arising out of that knowledge are not always in the best interests of humanity and the natural world. Furthermore, it seems to be in the nature of research that it will always push to the very limit of the controls that are set. That is why quite rightly both Houses of Parliament have taken pains to ensure that proper regulations and advisory bodies have been established to keep pace with advances in medical research.

There are three points that I should briefly like to make. Last autumn at the invitation of the Norwich Medico Chirurgical Society I took part in a debate about in vitro fertilisation and embryo research. I was impressed not only by the advances in knowledge and technique that had been achieved, but more particularly by the sensitivity and compassion with which its members spoke of their work. As one would expect, we could not agree about a number of issues, but I greatly admired the profound and sensitive care being demonstrated for the people they were helping.

Nevertheless, I remained uneasy. The reason was based on a Christian assessment of human nature, an assessment which I believe is also inherently rational: that is, that human nature is corruptible, our motives easily mixed and that we are not always capable by ourselves of judging what is best for the human race. That is why controls are always necessary and why, like many in my profession, I remain cautious and conservative in such matters.

The second point arises from another meeting of the Norwich Medico Chirurgical Society when, during its annual dinner three years ago, I asked a senior consultant about the composition of the local ethical committee. Several names were mentioned whom I knew to be expert in their field of medicine, thoughtful
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and some of them committed Christians. But none of them had any formal training in the field of ethics. It was characteristic of their generosity that subsequently I was invited to nominate a representative who had expertise in this area, and one of my clergy who has studied medical ethics for many years became a member of the committee and is now its chairman.

The point is this. When establishing regulating bodies to advise upon research, it is necessary not merely to make sure that the terms of reference are well balanced but also that the membership of such bodies includes those who have professional expertise in the field of moral judgments. Of course we are all engaged most days in asking ourselves about what is right and wrong—at least I hope we are—but for those in my profession it is also part of the work for which we are trained.

I have twice used the example of the Norwich Medico Chirurgical Society, which may not be a body well known to everyone. It was founded in 1867, I think as much a dining club as a gathering for academic discussion. They used to meet on the night of the full moon so that they could see the road better on their way home. If any of your Lordships is ever invited to address the society, I strongly advise acceptance. The company is good, the food excellent and instead of a fee they present their speakers with a case of very good claret.

My final point is more general. During the Second Reading of the Human Fertilisation and Embryology Bill the noble Lord, Lord Zuckerman—a valued neighbour of mine in Norfolk—said:
Science will never provide the answers to the ultimate questions: the question of what brought about what we call life and what it is that gives man his unique quality in the world of living organisms".—[Official Report, 7/12/89; col. 1041.]
I hope that I am not stretching those words beyond their proper meaning by saying that there is implicit in that humble agnosticism which is a characteristic of the greatest scientists the conviction that other disciplines, not least theology, have much to contribute in the search for truth and wholeness. However, in order to do so they must be in dialogue with one another and preferably in partnership. It is also necessary that each discipline practises the virtue of humility. That is the only proper attitude towards a search for truth, which is ultimately beyond the grasp of any single branch of knowledge.

It is in that spirit that I offer these brief thoughts concerning the vital relationship between the medical profession and my own and between the insights of scientific research and theological reflection. I wish to add finally that, as well as being conscious of the great privilege of belonging to this House I am most grateful for the kindness and generosity that have been shown to me as a new Member. I thank your Lordships for the courtesy with which you have listened to me on this first and somewhat terrifying occasion.

My Lords, in the 33 years during which I have been a Member of your Lordships' House this is the first occasion on which I have had the privilege of congratulating a maiden speaker.

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"Privilege" is not merely a conventional word; not only is it a privilege but it is an honour to follow such a distinguished, humane and wise speech. At a time when the Church is under a great deal of criticism —some of it not entirely unjustified—it would be good for those who criticise it to study well the speech to which we have just listened. The right reverend Prelate has a distinguished record. He trained at the Royal Military Academy, Sandhurst and in the Church as a whole. He is Bishop of a beautiful city which I know only as a result of time spent there when in the Territorial Army. The inhabitants of Norwich are extremely fortunate in having a bishop of such distinction. The more often the right reverend Prelate is able to address your Lordships' House, the richer it and the country at large will be.

I am a long-standing member of the all-party parliamentary chemical industry group. I was detailed into it by a Member of your Lordships' House, but time prevents me from giving a longer explanation. I pointed out that, as one who had spent his working life in the controversial world of insurance, my knowledge of chemistry and pharmaceuticals was less than nil. However, membership has enabled me to visit a number of pharmaceutical companies. I also have a young daughter who is a nursing sister and who sometimes keeps me on the straight and narrow. Therefore, I believe that the noble Lord, Lord Hunter of Newington, has, not for the first time, given your Lordships the opportunity to discuss an important subject. The pharmaceutical industry is responsible for 21 per cent. of the work carried out in research and development. According to a most interesting article in The Times supplement, a little more than £1 billion was spent in 1990 on research and development.

Perhaps I may recount briefly a personal experience. In 1941 I had a virulent attack of measles followed by a mastoid in both ears. Penicillin had not then been discovered and I had to rely on M&B. A nephew of ours has also suffered from a bad mastoid since Sir Alexander Fleming's great discovery. He is not completely cured, nor am I. However, I believe that those who criticise the pharmaceutical industry and have reservations about research and development—we are all entitled to our views—should bear in mind that those illnesses would not have been overcome if it had not been for research and development.

On two occasions I have had the pleasure of visiting Terlings Park near Harlow where an enormous amount is being done on Alzheimer's disease, Parkinson's disease and so forth. My wife and I have a friend aged 60 who is in the terminal stages of Parkinson's disease. As members of the medical profession will know, it is a most distressing sight. It makes one recognise the vital importance of the pharmaceutical industry.

The operative word in the noble Lord's Motion is "future". Due to the enormous amount of progress made in R&D and in the pharmaceutical industry, stays in hospital are short. I know that from an experience four years ago when I had my gall-bladder removed. If I had had the operation 25 years ago goodness knows how long I would have been in
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hospital. However, I stayed for only nine days. Short stays are due in no uncertain terms to the excellent work which people in this country have undertaken in research and development.

As progress is made we see breakthroughs in illnesses such as leukaemia. We have read about the child of one of our distinguished citizens who may have to wait four years before knowing whether the leukaemia has been cured. The more that is done in research and development, the more promising is the outlook for youngsters and elderly people.

Again, I congratulate the right reverend Prelate on a notable maiden speech and I thank the noble Lord, Lord Hunter, for initiating the debate. I am sure that at a time when the National Health Service has become a political football, my noble friend the Minister will note that this House has debated a Motion which even these days can hardly become the subject of party politics.

My Lords, I too thank the noble Lord, Lord Hunter of Newington, who, as on so many occasions, has given the House the opportunity of debating such an important subject. In particular, I wish to express my thanks and admiration to the right reverend Prelate the Bishop of Norwich. I greatly enjoyed his speech. I shall be in his diocese this weekend and I ask him to convey to members of the learned society of which he spoke my open offer to address them. If he does so I shall share the cask with him.

As time is short I wish to concentrate entirely on Alzheimer's disease, which was touched upon by the noble Lord, Lord Auckland. The principal demographic changes of the 1990s will not be an overall increase in the number of pensioners but a rapid increase in the number of elderly people, in particular those over the age of 85. The OPCS estimate is that the number aged 85 and over will increase from 865,000 in 1991 to 1,146,000 at the turn of the century. That is an extremely large number and an extremely rapid increase. It is that age group in which so many sufferers from dementia are to be found.

The people who are most likely to suffer are the very elderly. The number of people with Alzheimer's disease in the United Kingdom has been estimated to be about half a million. Dementia is usually a disease of old age although it occasionally affects middle-aged people. It is spread equally across all groups of society and does not appear to be linked with sex, social class, ethnic groups, geographic locations, or anything else. Recent surveys have revealed that the prevalence of dementia in the population is as follows: aged 40–65, less than one in a 1,000; aged 65–70, two in 100; aged 70–80, five in 100; aged over 80, 20 in 100. Therefore, we are talking about roughly 1 per cent. of our population and that is likely to increase. Therefore, it is extremely urgent that Alzheimer's disease is looked at not only as a medical problem but as a social problem. If there are half a million sufferers of Alzheimer's disease, there are at least another half a million caring for those people—mostly at home, but there are many in hospitals and nursing homes.

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I am proud to be closely associated with the Alzheimer's Disease Society. I greatly admire the work that it does and the work carried out by its research team. Not only do I admire the way in which families of those suffering from Alzheimer's disease are supported but I also admire the work carried out by its research team; in particular by Professor Wilcock who is a professor of care of the elderly at Frenchay Hospital in Bristol and chairman of the research panel of the Alzheimer's Disease Society.

The problems are great. Many of your Lordships will have recently seen the report that a leading research team at St. Mary's Paddington has been split up and that Dr. John Hardy and other outstanding researchers have moved to the United States. Of course, that will undermine some of the work being done at St. Mary's. That is an extremely sad situation.

Why are we suffering from the departure of some of our most able scientists to other parts of the world and especially to the United States? Perhaps I may mention a few reasons for that. First, there is the problem of university funding. Whatever the Government say about more money than ever being poured into universities, there is no doubt that the budgets for research are decreasing in real terms. Research which can be linked to industry is being encouraged but industry will not pay and medical research will not be encouraged unless there is a short-term financial spin-off. That is an unfortunate social approach to take to research.

Secondly, the Government would have us believe that they have increased adequately the Medical Research Council's funding. It is difficult to reconcile that with the increasingly alarming stories of the MRC's inability to fund projects which they have rated highly as important work which they wish to support.

There are problems also as regards remuneration. Salaries of research workers are poor compared with those available in industry and commerce. Many researchers earn considerably higher salaries if they accept an offer to work at, for example, a pharmaceutical company. I give an example of a PhD student. He undertakes three or four years as an undergraduate living on a grant. He is then expected to live on about £5,000 per year for the next three years while he undertakes his PhD. At the end of that time the researcher knows that the prospect of a job relevant to his PhD training is quite small because of the difficulties of funding. That discrepancy in salaries between research and industry is now so great, and the incentives for staying in university posts are so diminished, that it is no wonder that many are now looking across the Atlantic and, increasingly, to Europe for their future.

There are problems in the newly-constructed National Health Service. If we look at the situation of the purchasers and providers, the establishment of health trusts with strong commercial interests creates a possibility of conflict between the costs of immediate health service provision and the equally important need for facilities for clinical research. It would be disastrous if trusts started to charge more than
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justifiable overheads to those carrying out research, particularly if that research is being carried out by charitable bodies in health service properties.

How can we improve the situation? Much Alzheimer's disease research in this country is paid for by medical charities rather than by universities or the Medical Research Council. More resources are required and the universities should be dissuaded from charging charities the overhead costs which they currently demand from industry. Industry may make a profit in the long term but charities are not in the marketplace to make a profit. I should like to see the establishment of designated Alzheimer's disease research centres in different parts of the country. Certainly the problem demands that. A modest increase in resources could be used to establish regional research centres; for example, in Bristol, Oxford, Cambridge, Newcastle and London.

The problems which many of those researchers face are considerable. I take the example of Bristol. There is a team of 18 people with a spectrum of interests ranging from clinical research to the use of the techniques of molecular technology applied to the development of new therapeutic avenues. Fourteen of those people are employed on a temporary basis. Therefore, there is always the temptation for them to look elsewhere for permanent jobs. The accommodation is inadequate. One person is based in a kitchen of a Portakabin. The equipment is basic and much needed modern technology is simply not available because of the shortage of resources. In one laboratory seven research workers have to share an office space meant for two. That is almost as bad as the way in which some of us have to share office space in the House of Lords. Perhaps that is an exaggeration.

Finally, I am certain that we need greater Department of Health commitment to the problems of those with dementia. Much useful research could be undertaken if health authorities and trusts were charged with assessing the needs of those in the community suffering from dementia and with providing the resources to evaluate the most effective way of linking together the efforts of the National Health Service, the social services and the voluntary and private sectors. It is not just funding which is needed but also commitment and leadership from the centre.

My Lords, I join in the thanks and congratulations offered by many of your Lordships to the noble Lord, Lord Hunter of Newington, for initiating this debate. I join also in the warm and totally well justified congratulations to the right reverend Prelate on his quite superb and moving maiden speech. Having spoken to the Norwich Medico Chirurgical Society in the past, I echo his admiration for that organisation.

I apologise to your Lordships, to the noble Lord, Lord Hunter, and to the Minister for the fact that I may not be able to stay until the end of the debate because some weeks ago, before I knew of the debate,
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I agreed to speak to an all-party parliamentary group on complementary medicine at 5 p.m. elsewhere in the Palace of Westminster.

In this country we have a most notable record in medical research in our universities and our National Health Service hospitals. Much of that has been based upon developments in basic science, not least in recent years upon new techniques of imaging, molecular biology, immunology, pharmacology, and many more. It has been justly said that today's discoveries in basic medical science bring tomorrow's practical developments in patient care.

Many of the most crucial contributions towards such research come from consultants in our National Health Service who work in an increasingly close partnership with scientists in hospitals, in MRC units, in units funded by our charities and foundations, and in partnership with the clinical academic staff in our universities. They do so to such an extent that in many medical schools and their associated hospitals, clinical and academic staff who see and treat patients and consultants who teach, provide services which are virtually indistinguishable in relation not only to patient care but to teaching and research. They do so under the long hallowed "knock for knock" agreement between universities and hospitals—one of the cornerstones of work in research in this country.

Some of the finest research has come from our NHS hospitals and those who work in them. It is important to make the point also that, contrary to popular view, much of the work funded by the Medical Research Council is not basic laboratory research but is clinical research. I can only quote, for example, the extraordinarily competent trial of chiropractic versus outpatient hospital treatment in the management of low back pain and the more recent trial demonstrating the benefits of surgery on the carotid artery in the prevention of stroke. I could quote many more.

Some of the major developments come not just from our universities, MRC units and hospitals, but also—as the noble Lord, Lord Auckland, said—from our pharmaceutical industry which, in a previous debate, I called the jewel in Britain's industrial crown. Those developments are extraordinarily expensive. For example, the drug erythropoetin, which has been shown to be a rapid and effective means of controlling the anaemia of chronic renal failure, is enormously expensive. The treatment of migraine now made possible by the drug sumatriptan as a treatment for acute attacks is immensely costly. It was developed by basic research by Glaxo, Britain's leading industrial company, but it costs £20 for each injection.

We are now seeing tremendous developments in gene identification leading to major new progress in preventive medicine. I have spoken in your Lordships' House about the discoveries emanating from the isolation and characterisation of the Duchenne muscular dystrophy gene some years ago, not least in antenatal diagnosis but also in relation to the benefits of embryo research. Only two weeks ago from Charing Cross Hospital and in the Welsh National School of Medicine reports came that the gene responsible for another form of muscular dystrophy, adult myotonic dystrophy, has been isolated and
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characterised. That will unquestionably bring major benefit to the families of those patients, not only in prevention but in leading us closer to the prospect of gene therapy.

In saying something about gene therapy perhaps I can welcome the Clothier Report recently published by the Department of Health which gives us a lead in that direction and which will be helped enormously by the establishment of the supervisory committee which the Department of Health proposes to establish. In my view there is no doubt that gene therapy is becoming a real prospect as a means of treating effectively inherited disease. I venture to suggest that within the next 10 years in many of our worst and most crippling inherited diseases it will become a reality.

Those developments are not cheap and I ask whether society, whether government of any political party will swallow and accept the inevitable financial consequences. There are many clouds on the horizon. Are we to face explicit rationing of health care and of these new developments, as in Oregon, or is it to be implicit as it is inevitably in certain circumstances at the present time? I have spoken before about what I believe to be the extraordinarily short-sighted decision to remove the research infrastructure money from our universities and to hand it over to the research councils. I understand the reasons, but believe that it is a misguided decision which will be reversed in the same way as the Rothschild decision some years ago to take money from the Medical Research Council and hand it over to government departments had to be reversed. I hope that this will similarly be reversed. I learnt only two weeks ago that in the University of Oxford two of the brightest and most distinguished research departments are being faced with cuts. One will suffer a cut of £41,000 in the budget which provides that infrastructure of staff, secretaries and technicians so crucial to their research programme, and the other with a cut of £113,000 because of that decision.

In the National Health Service we have SIFTR—the service increment for teaching and research. That is part of a dual support system which enables research to be carried out in our NHS hospitals. Is it adequate? The costings of various procedures in some of our teaching hospitals suggest that the adequacy of that component is in doubt. Perhaps I may echo also the point made by the noble Lord, Lord Ennals, that if the removal of the research infrastructure money from our universities results in the universities being compelled to charge charities overheads on research grants, it will have a devastating effect on the money hard-earned by many of those bodies throughout the United Kingdom.

My final point relates to staffing. I speak as president of the World Federation of Neurology. We had a symposium at the Pan European Congress in December, talking about the American Congress's decision to call the 1990s, "The decade of the Brain". It discussed the establishment of consultants in neurology throughout the world—10,100 accredited neurologists in the United States, 4,500 in Japan, 1,100 in Germany, 179 in the United Kingdom and only Ireland, with six, fares worse in the developed
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world as matters stand at the moment. It is therefore not surprising that neurologists find it difficult, in the face of the load of patient care that they inevitably carry, to carry out the research of which many are capable.

I trust that the Government's programme of expanding the consultant establishment in this and in many other disciplines—so crucial to the future of medical research in our hospitals—is something that will gather pace. We could double the number of consultants, inevitably reducing in consequence outpatient waiting times to see them, bearing in mind the numbers of patients they are required to see at the moment. I am a passionate believer in the National Health Service. It has the potential to contribute in an extraordinarily effective way to future research leading to major developments in patient care in this country. But it is something that will need increasing attention not least in a financial sense.

My Lords, as a layman perhaps I may add my thanks to the noble Lord, Lord Hunter, for initiating this debate to which such distinction has been added by the maiden speech of the right reverend Prelate the Bishop of Norwich.

The noble Lords, Lord Hunter and Lord Rea, and the noble Viscount, Lord Falkland, mentioned the need to address the needs of the patient. The point I wish to bring to your Lordships' attention is a simple and I hope a brief one. It concerns the necessity to strike the right balance between the centres of excellence in research and those parts of the country where the burden of disease is greatest.

The largest centres of excellence may be said to be London, Oxford, Cambridge and in Scotland. In the case of England alone—I address these remarks only to England—it is presumably an accidental but interesting fact that the regions covering those centres —namely, the four Thames regions, Oxford and East Anglia—accounted for six out of the eight regions with the lowest mortality rates (and the three lowest overall) for persons under the age of 75 in the period 1985 to 1989. The six lying at the other end of the scale were the six northernmost regions of England.

If your Lordships will bear with me, I have one more significant statistic. In 1989–90, the latest year for which figures are available, the four Thames regions, Oxford and East Anglia accounted for 39 per cent. of the population but received 77 per cent. of the external medical research moneys administered by the universities. The remaining eight, including those with the highest mortality rates—namely, the West Midlands, Trent, Mersey, Yorkshire, the North and the North West—with 61 per cent. of the population received only 23 per cent. of the external medical moneys.

I have to declare an interest in that as a special trustee of the Hammersmith Hospital I have a connection with the Royal Postgraduate Medical School which is well and truly in what one might call the better endowed group. Nevertheless, I hope that my noble friend the Minister and her colleagues in the
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Department of Education and Science will consider that there may be a case for making available a greater share of the research budget to those high quality centres of medicine in the Midlands and in the North of England which have the advantage in medical terms of lying in the heartlands of those parts of the country where the burden of disease and relatively high mortality are greatest.

My Lords, I too would like to thank my noble friend Lord Hunter for giving us the opportunity to discuss this vital subject, and I congratulate the right reverend Prelate the Bishop of Norwich on his maiden speech. I for one have an ethical dilemma as to whether I should be in this House this afternoon or over the road in Church House with the General Synod discussing the care of the mentally ill. I am so glad that I chose to be here and to hear such a distinguished address with such sensitive, ethical and theological insights.

Great progress has been made in a relatively short time since the Select Committee on Science and Technology reported on priorities in medical research. The appointment of a director of research and development has given us a basis for great progress. I believe that I can do no better than quote what he said at the beginning of his Francis Fraser lecture to the Royal College of Physicians in which he reported the state that he found. He said:
Over four decades the National Health Service (NHS) has responded to a huge range of innovations. Some have been durable, others have been transient; some have been evaluated but many have not. Often new developments have been superimposed on existing practice, creating a kind of medical archaeology where the remnants of earlier practices are discernible among the newer acquisitions".
He said:
the best use of human and other resources, and the contribution of medical interventions to the health status of individuals and the population",
needs to be studied. He continued:
The challenge now is to introduce a sensible mechanism for handling within the NHS the output of basic and applied research and to apply research methods to examine the content and delivery of health care".
I admire the speed with which the director has set up a strategy for developing research and development in the National Health Service, first, with the central research and development committee and the infrastructure at regional level. He is right in his analysis that there is need for a whole range of types of research, from the pure or academic research to applied research, development and evaluation research.

My purpose in participating in the debate is to attempt to underline that the NHS is a very large-scale organisation in which all kinds of professional practice, function and occupations have to be melded together for the care of the patient. Additionally, we have to look at the use of buildings, their design, the use of equipment and high technology. All these aspects need to be researched and developed in the interests of the National Health Service.

So research and development in the National Health Service cannot be limited to the medical function. Great emphasis has been placed on the
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importance of that aspect this afternoon, and that is right and proper. But there are many other factors involved in the National Health Service. Perhaps I can illustrate that best by reference to the need for research and development in my own profession of nursing. In doing so I shall make the case for other professions in the National Health Service such as physiotherapy and clinical psychology.

It is plain that nursing gives 90 per cent. of the care in the National Health Service. Nurses represent 50.9 per cent. of the National Health Service workforce and 45 per cent. of the wages bill. I believe it follows that the effectiveness of nursing intervention and the efficiency and effectiveness of the nursing service profoundly affect the total performance of the National Health Service.

But nursing has come late to the research scene. Some of the first pieces of clinical research were sponsored by the then Ministry of Health in the mid-1960s. Although there has been generous funding by the Department of Health and other funding sources for the past 25 years, there has been relatively little basic work which can inform nursing practice authoritatively. Therefore, I look at the way in which we practise nursing. For the most part, it is born of tradition or perhaps unsystemised experience on the part of ward sisters. All that, as in many other professions in medicine, needs to be subjected to analysis and research.

Fortunately, a strategy for nursing research and development is now evolving which should complement and be part of the strategy for research and development in the National Health Service. In 1990 the Secretary of State for Health endorsed the report on a strategy for nursing which indicated that research was an integral part of all the target areas in nursing—in clinical practice, manpower, education, leadership and management. The Advisory Committee on Nursing Research took the matter further, and, again under the aegis of the chief nursing officer, a multi-disciplinary group gathered at Wonersh last year to develop a strategy for nursing research.

In its report the group draws attention to the context in which a strategy for nursing research is being developed; that is, the new organisation of the NHS and the implications of the purchaser-provider approach. The research is taking place in the context of the national research and development strategy for the NHS and of rapid development in research into matters of audit. It is also taking place in the context of reforms in nursing education and Project 2000 and in the context of the regional structure and its effect on generating priorities.

At the Wonersh seminar we drew attention to the fact that research was needed over the whole continuum, from basic to theoretical research in nursing. We needed to look at application, development and dissemination of research results. We recognised that a wide range of methodologies would be required. Above all, we looked at the importance of collaborative and multi-disciplinary research. It was seen that the purchaser-provider approach to health service delivery was an opportunity for us to look at outcome measures in far more
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detail so that the expected standards of nursing care could be stated. The development of standards for contracting for nursing care and the need to update and educate staff now become a managerial imperative, and research has to contribute to that. So I look forward with confidence to improvements in research and development in that area of the health service.

My Lords, in offering my thanks to the noble Lord, Lord Hunter of Newington, for providing us with the opportunity to have this worthwhile debate I also congratulate him on his speech. It was somewhat poignant and realistic when he mentioned that research one day—I think that is what he meant—might even cure cancer, Parkinson's disease and all of the terrible ailments which still exist and which perturb us greatly.

I hope the Minister will be able to answer a point that I want to make immediately. When changes take place in the National Health Service in research, and so on, I hope that some endeavour will be made to inform the general public of what is happening so that they can have confidence in those changes. It is very difficult for people to realise that at one time there was not even an organised ambulance corps. That has developed and improved over the years until in this country it is first class. No longer are drivers merely drivers; they can do all sorts of wonderful things. But some people resent it when a driver wants to help while getting them into the ambulance on the grounds that because he is not a doctor he does not know what he is doing. In fact, as the General Secretary of the Confederation of Health Service Employees said some time ago—as did a noble Lord from the Benches opposite—an ambulance driver can be very useful in helping doctors and surgeons. Therefore, I hope that finance will be a priority for research and development in our NHS because in the end it will pay for itself.

I should like to congratulate the right reverend Prelate the Bishop of Norwich. His speech on ethics was very important. It took me back to the days when, in the Gallery of this place as a young soldier, I listened to another great Christian—a somewhat fiery Baptist Welshman—who through all his life maintained the ethic that to make money out of disease and suffering is devoid of any ethics whatever, let alone the Christian ethic. Nye Bevan was right then and he is absolutely right today.

I ask the Minister to realise that most people who work in the National Health Service appreciate the fact that ever since the inception of the NHS this country has been in the forefront of all forms of research and development. In world history it is amazing what research and development has achieved, despite it being somewhat haphazard. However, it did not become properly organised until we had our NHS; and recent Government endeavours have been well worthy in this respect.

The World Health Organisation has underlined that the philosophy of improving health with broad strategies for improvement are vital. Therefore, I believe that with political support emphasising the
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role of specialist education—that is important—we can improve on the research in which we already lead most other countries. I believe that this is not merely a matter of research and development. The results of research and development must be made available to all our people. The development of the National Health Service—it has been a great development —in British social history is the culmination of a great ideal; it endeavours to be comprehensive and wholly available to all people at all times. That is the ethic that we have to maintain with our research and development.

Referring again to ambulance drivers and similar workers research and development in medical engineering and medical mechanical devices is still needed. It is very important to have the right kind of equipment to move a person, who needs to be moved gently, from one floor to another, especially if a lift is unavailable. All these aspects are very important to our health service.

The importance of public health with preventive programmes, including attack on poverty, poor housing and industrial dangers, must be looked at. I come from a part of our country where it was quite normal to hear someone say, "Poor old soul, he died. He was only 48, you know, but he had the dust so early". A coal miner who had worked for about 12 or 15 years had died because the dust from the coal underground where he was working killed him. There may be other things knocking about which are an industrial danger. I know that the Minister will accept that we must have some form of research and development into occupations which are dangerous and which create great hazards.

There is a need for change and restructure to prove the efficiency and availability of the NHS. The General Medical Services Committee produced a valuable strategy paper called Building your own Future. The paper covers a vital aspect of the NHS and its relationship to the community as a whole. That document, coming from a great organisation, I feel sure will have the attention of the department. The Government responded to the House of Lords Select Committee very well and said that the NHS needed coherent research and development. That was a good response from the Government. I ask the Minister to see that they continue with that approach to R&D.

The NHS needs results and resources. It still needs vital skilled manpower. If we are to have research and development and create wonderful new machines and wonderful ways of doing this, that, and the other, then we have to make sure that we provide the training for those who operate the results of R&D so that they do so in an efficient manner. That is what I meant when I spoke in this House recently on the valuable contribution that can be made by all the staff associations like the Confederation of Health Service Employees, the British Medical Association and those of British nurses. All those organisations can contribute by saying what they require, which the brains of the researchers can do their best to provide. That calls for great teamwork between the intelligentsia of research and development. They in turn must
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listen to the doctors, consultants, nurses, and so on, as to their requirements. That will help us enormously. Doctors sometimes find it difficult to keep up with R&D. I hope the Minister will bear that in mind. I think that the Government should be a little more generous towards GPs with post-graduate expenses and to all other staff who are temporarily taken out of their jobs to study the possibilities of better R&D.

This debate is of vital importance to all aspects of our nation's endeavours: to industry, commerce, defence and education. Research and development in the NHS—possibly not in our lifetime—can erase much suffering and disease. I believe that R&D in the NHS will be good for our children and for our future.

I should like to conclude with one point. It was this nation that created this great National Health Service, which became the envy of the world and which I am pleased to say is now being copied by other countries and has resulted in an interchange of ideas between our country, America, parts of the Commonwealth and parts of Europe. That could never have happened without the National Health Service. My ultimate plea is that in doing all these things I hope that we can also provide help to the suffering and deprived humanity in the third world. In this country we are well on our way to a very good society in regard to health but the third world has not yet got to first base. Perhaps through our endeavours in research and development we can contribute to the alleviation of the suffering and the awful anxieties and worries of the third world.

My Lords, I too should like to thank my noble friend Lord Hunter for initiating this fascinating debate which has ranged all over the world. I should also like to congratulate the right reverend Prelate the Bishop of Norwich on his superb maiden speech. Of course, the Cambridge University Medical School falls in the neighbouring diocese. Like my noble friend Lord Walton, I have also had the privilege of addressing the Norwich Medico Chirurgical Society. I guess that it is a sign of my Alzheimer's disease that I cannot actually remember receiving any wine from the society 20 years ago. However, that may be the fault of my memory.

I should also like to tell the right reverend Prelate that in most ethical committees the presence of a layman is demanded. In Cambridge we have been greatly helped by lay members. Indeed, there is a close association between the clinical school and the religious people who attend the Addenbrooke's Hospital. I hope that we shall not get into serious situations in that connection because it is very important. In fact, I am known among some of the medical students as the man who believes that we need to go back into history to the time when religion and medicine walked arm in arm down the corridors of hospitals.

I am most grateful to my noble friend Lord Hunter for tabling the Motion at this time. I hope that it is not inappropriate if I say how good it was to see Professor Michael Peckham in his proverbial bow tie earlier today. I am sure that he will read all our messages in Hansard. I know that we all wish him well in his vitally
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important task. We thank the department for setting up such an arrangement. It is marvellous to realise, as the noble Baroness, Lady McFarlane, said, that he is beginning to build a pan-national framework of research and development committees.

I feel that I should remind your Lordships where all the research and development goes and mention one or two of the problems about which some of the people in this great chain are worrying. Of course much of the work must take place in universities. We are very proud of our work in Cambridge. Indeed, one might argue that medical research began in Key's College when a man called William Harvey, by doing some remarkable biological experiments, discovered how blood was circulated. The noble Lord, Lord Molloy, made the wonderful point that we have maintained a world leadership in such matters.

Only yesterday I visited William Harvey's hospital, St. Bartholomew's. I listened to people talking about research of the cells which actually envelop the circulating blood—the so-called endothelium. Is it not extraordinary that those same men, and those in other parts of the world, have been able to show that a very simple gas—namely nitric oxide—is probably the gas which dilates the blood vessels when they need to dilate. It is opening up an enormous amount of very important research and may lead to the development of new kinds of medicine for dilating blood vessels after people have suffered coronaries.

Of course there are problems in the universities which I should not conceal from your Lordships. Those concerned are worried that their medical teaching hospital departments may suffer from the new form of funding on a per capita basis. I very much agree with the noble Viscount, Lord Bridgeman, about the importance of ensuring that funds for research and development get through to the apparently less privileged parts of the country.

It has been pointed out that research councils are in difficulties. They have coming towards them now this wonderful tide of brilliant young people who are really experiencing difficulties in prosecuting their careers. I do not know how we can solve the problem because such young people have an almost exponential growth of brilliant new ideas which need developing. Perhaps we must teach them to walk barefooted and to live on bread and water—they will certainly need all their spare money to buy the necessary apparatus—or, alternatively, perhaps they will have to learn to share their apparatus in order to manage.

The research work that I observed yesterday at St. Bartholomew's is multiplying further investigations. No one can say which of those investigations will hit the jackpot. That is one of the big problems about research. The noble Lord, Lord Todd, when saying farewell as president of the Royal Society, made a great and wonderful remark which I frequently quote to students. I shall repeat it in my Scottish accent. He said, "Aye, there is only one thing that you can be sure of in research and that is that the results will surprise you". That factor is very important for the reputation of the research councils. I agree with my noble friend Lord Walton about the pharmaceutical industry being the jewel in our industrial crown. The work it carries
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out in research and development in this field is a great credit to the scientists who undertake the work and to the people who offer the leadership.

We should also remember the very important interactions which are essential in research and development. I shall deal presently with my personal concern and commitment for health promotion. That is not a very topical topic in some quarters; but it seems to me to be quite important. It will be greatly helped by the research into the genetic code —the human geno research. If we are to identify who is really at risk from smoking, it will probably come from that kind of approach. Then, as the professor, I shall not have to wonder how I can answer the student who says to the assembled company, "Well, Prof, it is all very well you saying don't smoke, but my grandfather smoked heavily until he was 102 and then died under a bus". I hope that the geno boys will be able to tell us who is the man who will die under the bus.

I want noble Lords to know that in The Patient's Charter there are two lovely quotations. The first says that the patient should be,
guaranteed admission for treatment no later than two years,
after the day that he or she sees the hospital doctor. We all know that there is terrible pressure on the National Health Service. The second quotation is to be found on page 21. It points out to the patient that he or she will be given help and taught,
how to maintain and improve your own health".
That seems to me to be a great reason for encouraging health promotion.

I worked in health education for a long time. However, I am afraid that the lessons tend to be dull. We need to enliven them: research can enliven them. We have certain ways of achieving a great leap forward in health promotion. The first example that comes to my mind is the terrible tragedy which took place at King's Cross tube station where many people died. The Underground authorities were immediately given the opportunity to impose a "No smoking" ban on the Tube. It is part of a most wonderful sea change, a level of consciousness change, in our country about the risks of smoking.

Of course, it must be said that obesity, which was a very dull subject 20 years ago, was greatly helped by a French company. It realised that the subject of obesity could be most interesting for general practitioners if they received new research information about it which would keep them, in their discussions with their fat patients, a little ahead on the information front. Those are areas where I believe that health promotion research could provide assistance to help people maintain their own health and thus reduce the pressure on the health service. That will become increasingly important as there are so many elderly people today.

I have one last point to make. I apologise to the House for having exceeded my time. I cannot escape the conclusion that health promotion is all pervasive in education, in transport, in health and in food. I hope that the Secretary of State will be given the
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authority to form a kind of health Cabinet to ensure that the various departments work together in the way suggested by the noble Lord, Lord Molloy.

My Lords, I begin by thanking the right reverend Prelate the Bishop of Norwich for his maiden speech and congratulating him on it. I congratulate also the noble Lord, Lord Hunter of Newington, on enabling us to have this brief debate on a subject of enormous importance.

I should like to concentrate on the issue of research and development. The national health system benefits from the research that is carried out by alternative and complementary medical colleges, such as those of the chiropractors and osteopaths among other alternative medical groups. The results of chiropractic research into the importance of the spine as a channel of fluids and on the nervous system are of enormous help to people who are attempting to diagnose the cause of cot-deaths. My noble friend Lord Walton, among others, has promoted National Health Service recognition of such alternative medical groups. As was stated by the noble Lord, Lord Holderness, collaborative research is essential if the population as a whole is to benefit from the National Health Service.

Finally, I wish to back my noble friend Lord Walton in promoting further funds for neurosurgery and neurology as a whole. Without British neurosurgeons and neurologists, I would not have the three of my 1 million nerves that go from my optical cerebrum to my two retina. I thoroughly support the Motion.

My Lords, like all speakers, I should like to thank the noble Lord, Lord Hunter, for tabling this Motion and giving us a chance to debate this important subject. There have been many excellent speeches but none better than the maiden speech of the right reverend Prelate the Bishop of Norwich, who gave us a timely reminder of the importance of ethics in our considerations of medical research. He referred to the Human Fertilisation and Embryology Act. All of us who participated in debates on that Bill agree with everything that he said about the importance of ethics in our consideration of medical research.

If health research is to be successful, it must have the three elements of innovation, prevention and evaluation. Innovation is necessary to cure diseases, to save people's lives and to improve the quality of life. Prevention is necessary to find out what makes people stay healthy. Evaluation is the measurement of the effectiveness of the treatment and of changes in life-style.

I am sure that we would all agree that research and development must be seen as part of an overall health strategy. The prime function of the health service is to help people to stay healthy and, if that fails, to cure them as quickly and as effectively as possible.

I should like to raise a particular point with the Minister on the question of innovation. An important part of innovation is to protect the effective patent life
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of new medicines. Paragraph 6.8 of the Third Report of the House of Lords Select Committee on Science and Technology entitled Priorities in Medical Research, which has already been referred to, states:
The Government should ensure that the patent protection available to the pharmaceutical industry in the United Kingdom in practice affords levels of protection similar to that afforded by the patent laws in major competing countries, both in Europe and in the United States and Japan".
Paragraph 2.3 of the Government's response to that report states:
further progress in protection of pharmaceutical patents would require collective action by a number of European countries".
The House will be interested to know the latest state of play on that, whether the Government have been able to make any progress and the influence of the European Community's draft directive on dispensing which is to be effective from January 1994.

Only the other day I was discussing the environment for research and development in this country with the directors of a drug company that is a subsidiary of a major international group. They were not wholly optimistic, partly because of the pressures on the science base but also because of the problem of the protection of patent life and the knock-on effect on research and development.

Turning to prevention, my party is proposing a health initiative with specific targets and the Government have issued their health promotion White Paper. A number of your Lordships have referred to the importance of the environment not only in relation to research and development but in relation also to tobacco advertising, random breath testing and nutritional guidelines for school meals. One problem that we have hardly addressed is the effect of poverty on health and the differences in health that are due to inequalities, such as the difference in the incidence of disease between the social classes.

We must balance health education with treatment. There is now a shift towards providing much more treatment at the primary care level. In considering evaluation, the new developments in medical technology offer dramatic improvements in patient care. I refer, for example, to lithotriptors which are used to smash gallstones; to laser and fibre-optic technology; to the move from intrusive to key-hole surgery and the move towards day surgery. All those changes need to be evaluated and monitored. Indeed, concern has already been expressed about the need for after-care with day surgery. That is research and development at the practical level. The Opposition believe that, in terms of evaluation, there should be a freedom-to-publish clause in the contracts of Department of Health researchers. Indeed, my party is committed to a freedom of information Act. It would be interesting if the Minister could comment on that recommendation and on the concept of a freedom-topublish clause.

The excellent Priorities in Medical Research report included powerful arguments that reveal just what needs to be done if we are to meet the research and development needs of the health service. However, several doctors who have been in touch with me have expressed concern that, with all the current changes in
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the health service, the needs of research and development may well be squeezed out at the most basic level. I should like to quote from a letter that has been sent to me by a leading cardiologist which states:
On a personal note, one thing which saddens me is that the increased amount of administrative work that I am having to do (I think about 10 to 12 hours a week) means that I have had to give up any attempts at research work. I have 6 'papers' which 1 could and should be writing, either alone or with junior colleagues, and I see no prospect of doing anything about them before May next year when I expect that I shall take early retirement at the age of 60".
That is not the best use of scarce research resources.

The department has produced good documents on research and on health in the regions. Strong emphasis needs to be placed on the role of the regions in research and development. Are the Government entirely satisfied that there will not be a dissipation of the research effort away from our centres of excellence, given this shift towards regional research and development? What evaluation is taking place to ensure that the research effort is not dissipated away from our well-known centres of excellence which sometimes have a world reputation?

Turning to development, I should like to touch on a subject which has not yet been discussed. I refer to community care because that is part of our health service. I have searched all the various documents that relate to research and development but I cannot find any reference to research and development into community care. The Motion refers to "development" as well as to "research", and that includes training. The implementation of the community care plans in April 1993 is a topical subject, so perhaps I may ask the Minister what research is being carried out into that area. What research is planned, and who is responsible for it?

As I have said, development can include training. Indeed, the best R&D in the world is of little help if there are no properly trained people to put it into effect. As I mentioned this to the Minister before the debate, may I ask her now whether the Government are satisfied with the current efforts in terms of research and development and training for community care in both the private and the public sectors? What are the training arrangements? Where does the ultimate responsibility lie for R&D and for training standards? Does the director of R&D in the health service have any responsibility in this area?

I have been asked by several organisations about the national vocational qualifications—the NVQs—in social care and health care. What is the research base for the development of and training in community care? What use is made of NVQs in that area, and are they to be expanded? I have heard only recently that the Audit Commission is to produce three reports on community care. Which areas of community care will be covered by those reports, and will they deal with research and development?

Also on the subject of care, the noble Baroness, Lady McFarlane, mentioned nursing. An excellent report for the Royal College of Nursing was undertaken by the Institute of Manpower Studies. It was a first-rate analysis of the problems facing the RCN. There is the problem, of which we are all aware, that, while the workload has increased as broadly
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measured by the number of patients treated and by the higher average dependency level of those patients, the number of nursing staff employed in the NHS (whole-time equivalent) has remained comparatively static, with little real increase since the early 1980s. An increased workload, with static staffing means an increase in stress and an increased dependence upon support workers in nursing. It appears that not much work has been done on the cost-benefit ratio for nursing care, the costing methodologies, the organisation of nursing, skill mix, skill substitution and specific nursing intervention.

The report concludes:
This review has revealed that much research based work has been undertaken to monitor and measure the 'value' of nursing. However, the work is fragmented and mainly rooted in a US context. Given the current attention to cost containment in UK healthcare, it is evident that further research is required which develops common methodologies and links costs to outcome in order to ensure that cost effectiveness is not overlooked in the drive for cost savings".
I should be interested to hear the Minister comment upon that.

That quotation mentions the outcome of treatment. We now have a great deal of information about throughput and we have some information about costs. The health service debate has become a battle of statistics about waiting lists, the number of patients treated, the utilisation of beds and so forth. All that says little about the outcome of treatment—to use the jargon, the cost/benefit ratio. The noble Lord, Lord Hunter, referred to the use of quality adjusted life years. He thought that that was the wrong approach. I agree with him, because that approach depends upon costing procedures and a knowledge of costs.

I have spent all my working life in a specialised area of management accounting. All cost accounting is a mixture of convention, heroic assumption and arbitrary allocation. That is all right when one is costing a widget. But I agree with the noble Lord about the danger of' using the concept of quality adjusted life years when someone's life depends upon it. He remarked about consensus management. We can all agree with that. I wonder how we are now to practise consensus management with the commercial confidentiality of the purchaser-provider contracts, the confidentiality of the business plans and so forth and the denial of freedom of speech for the people involved who are not allowed to comment upon them. How are we to build up consensus management in that area?

As I have said, we have had an excellent debate. As is often the way with these debates, we have asked many more questions than we have answered. We are looking forward to hearing the Minister's reply. I hope that she will be able to agree with all noble Lords on the vital importance of research and development if the health service is to perform the tasks that the nation demands of it.

My Lords, I too am grateful to the noble Lord, Lord Hunter of Newington, and to all noble Lords who have contributed to the debate, for giving me the
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opportunity to give what is, in effect, a first year's report on developments in the important area of research and development in the NHS. As the director, Professor Peckham, has been very vigorous, a great deal has been achieved. The debate has also given us the opportunity to hear from the noble Lord, Lord Carter, something about his party's plans in this area. I shall read, study and evaluate his comments with great interest.

I first wish to add my congratulations and thanks to the right reverend Prelate on hitting the right note with his maiden speech. Ethical considerations add an important dimension to all that we have been discussing. He will be pleased to know that we have pre-empted some of the issues he raised by issuing new guidance to local research ethics committees.

I shall preface my remarks about some of the main issues raised in the debate by referring to some good news. First, the health departments have just reached agreement with the Medical Research Council at working level on a new five-year concordat governing co-operation between those major government funders of medical research. The agreement awaits only formal ratification. The MRC has been very responsive to the need to take greater account of health problems of concern to health departments and the NHS, without losing sight of scientific opportunity. Agreement was reached cordially and without major disagreement. This augurs well for the success of the concordat.

Secondly, we promised in our response to your Lordships' report Priorities in Medical Research that we would take steps to enhance the exchange of information with other research funders. In addition to normal working contacts, we have promoted and encouraged the creation of research liaison committees that bring together funders in particular areas, building on the experience of the United Kingdom Co-ordinating Committee on Cancer Research. One has started work on cardiovascular disease and stroke, and another is being set up on respiratory disease. We shall carefully consider the creation of others as the need arises.

The noble Lord, Lord Rea, was the first of your Lordships to ask about funding. In announcing the R&D strategy for the NHS in April last year, we made a commitment to increase the proportion of NHS spending on R&D to 1.5 per cent. over five years. We have started to move towards that increased investment by including £7 million of "tasked" money in regional health authorities' allocations for the coming year. That is designed particularly to enable them to develop the systems and structures which they will need in order to implement the strategy. That is just a beginning.

Something over £1.5 billion is spent each year on health R&D from all sources. The Government spend over £500 million currently, and the NHS spends over £225 million. That amounts to about 1 per cent. of total NHS spend. The Government intend to raise that figure, as I have said, to 1.5 per cent. over five years.

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The main aim of the strategy is to ensure that the content and delivery of care in the NHS are based on high quality research relevant to improving the health of the nation. We intend to see R&D become an integral part of health care so that clinicians, managers and other staff find it natural to rely upon the results of R&D in their day-to-day decision making and longer-term strategic planning. That is an ambitious goal and will take some time to achieve. Looking back on the past year, I am confident that we have laid firm foundations upon which to build. Those foundations include the establishment of a Central Research and Development Committee, to which reference has already been made. It is chaired by Professor Peckham, and has the prime task of advising on priorities of the NHS R&D programme and establishing a framework for the development of regional R&D plans.

The CRDC brings together senior NHS managers, leading researchers from the universities—so preserving the contact with centres of excellence about which the noble Lord, Lord Carter, asked—and from elsewhere, including lay members, and others with experience in industry. The CRDC has held two successful meetings, and will advise us on areas in which R&D will be of value to the National Health Service. It will distinguish between areas of national priority which merit central National Health Service funding, a larger number of areas of national importance on which National Health Service R&D should focus and health service needs which might be drawn to the attention of other funders, such as the Medical Research Council. This would be reflected in the proceedings of the new concordat.

Identifying a suitable list of priorities from among the many possible areas of health-related R&D, as your Lordships' contributions this afternoon have emphasised, presents a mammoth task and one as regards which none of us, I am sure, would envy the CRDC. I believe that it will contribute to the consensus rationing to which the noble Lord, Lord Hunter, referred. One of the first principles that the central committee has established is that its business should be conducted as openly as possible. CRDC papers are already circulated widely throughout the National Health Service and the research world. The CRDC's business programme will include consultation and open discussion of its work. I feel sure that this approach will be welcomed. Indeed, it is a prerequisite of sound priority setting.

On the subject of the freedom to publish research, within the National Health Service research and development programme—a point raised by the noble Lord, Lord Carter—researchers will be encouraged to publish research findings and there will be emphasis on the free sharing of the results of individual projects.

The CRDC will explore four broad areas when considering NHS R&D priorities. These are: disease-related work; organisation and management of services, including operational research; client groups, including disabled people—I can reassure my noble friend Lord Holderness on that point—and last but far from least, consumer groups. We have already started one disease-related work programme with a
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mental health research advisory group which is working to identify priorities in the field. It will report to the CRDC within the next two months. This will cover the subject of Alzheimer's disease, to which the noble Lord, Lord Ennals, specifically drew our attention.

Other reviews are planned for later in the year, including one in the area covered by the organisation and management of services, and a review of research needs in the field of cardiovascular disease.

An advisory group on health technology assessment has already produced a report for consideration and doubtless that, too, will cover some of the points raised by the noble Lord, Lord Molloy.

The second key element of the strategy is the devolution of most of the management of R&D to regional health authorities. We have asked each regional health authority to identify a member responsible for R&D. We have also asked RHAs to appoint regional directors of research and development early in the coming financial year. Four regional directors have already been appointed. The other 10 are well on the way to appointment and it is extremely gratifying that these research and development posts are attracting high calibre appointees, strengthening the links with centres of excellence.

Each regional authority has also been asked to appoint a multi-disciplinary regional research and development committee early in 1992–93, to advise the region on the content of its R&D plan and on the region's input to the Central Research and Development Committee. It will also ensure the quality of that research and I believe that this approach will go a long way to meet some of the specific anxieties raised in the course of the debate.

For the first time we are asking regions to identify their own research and development priorities. We fully appreciate that this is a new and difficult task and we do not expect them to come up with the perfect regional strategy all at once. However, we expect them to do the best they can and to continue to refine and improve their regional R&D plans year by year. It is essential that they do so if research and development is to fulfil its raison d'etre of serving the needs of the National Health Service.

The research which the RHAs commission will fall into three main categories. First, they will be able to bid for central finance to manage research in areas of national priority identified by the central committee. Regions will develop research programmes in those areas and let contracts to research bodies. Secondly, regional health authorities will use their own funds to let contracts for research in areas of national importance identified by the CRDC.

Thirdly, regions will let contracts for research in areas which they themselves have identified as priorities. These may be matters of local as well as of national concern. They will obviously be concerned about the patterns of health within their own regions and will address them as part of their R&D plans. We intend that they will, however, be free to commission research from those centres within or outside their own region best placed to undertake the highest quality work. I hope that this will reassure my noble
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friend Lord Bridgeman. We very much intend that there will be a free flow of information under this strategy so that regions can also use the results of appropriate research and development undertaken elsewhere.

Perhaps I may also refer to the role of the London postgraduate special health authorities in the strategy. They and their associated institutes will continue to be major providers of research and development for the National Health Service. They will be able to hid alongside regions for the management of programmes of centrally-funded R&D, and may undertake R&D on contract. They will also continue to carry out their own R&D activity so that there will be continuity.

SHAs have provided us and the CRDC with position statements of their R&D plans. Each paired special health authority and institute is also jointly nominating a senior member of staff who can fulfil the role of director of research and development for that organisation.

We also see a major role for the regional directors of research and development, with a representative from the special health authority/institute directors of research and development, in working as a group with Professor Peckham to manage a co-ordinated national programme.

We are currently establishing an information systems strategy for research and development. The objective is to ensure that National Health Service resources are deployed to maximum effectiveness. This will be achieved by developing systems which provide comprehensive and up-to-date R&D information on matters of direct relevance to patient care services. This information will be extremely important to many people, including, for example, clinicians and managers involved in placing contracts to purchase services.

I have been encouraged by the positive reactions from the National Health Service to our strategy. Regions in particular have grasped the importance of ensuring that R&D is integrated into the management agenda. We are working with them to help them develop the infrastructure that they will need in order to take on the research and development management task. We held a successful workshop for regions on 4th December, from which many helpful ideas emerged.

Perhaps I may attempt to answer some of the many specific points and in advance I hope that noble Lords will understand if I do not cover them all. The noble Lord, Lord Hunter, questioned the Government's view of the use of quality adjusted life years. I can tell the noble Lord that measures of quality adjusted life years, or QALYs as they are sometimes called, can provide useful information on health outcomes. However, there are concerns about some of the uses to which it has been suggested they might be put. The noble Lord remarked on that. The department is funding a programme of work to develop and evaluate those measures further.

The noble Lord, Lord Rea, asked how our National Health Service reforms are being evaluated. We are learning by experience and we are looking at quality of care, value for money and more
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responsiveness to individual patients, for example, through the reduction of waiting times and waiting lists. The first six-months report, which was issued just a few weeks ago, provides a good indication of how well the National Health Service is responding. The noble Lord also asked about research to follow up Department of Health inquiries into health care needs. We have commissioned a range of research to support the new purchasing role of district health authorities. This includes a series of epidemiologically based needs assessments governing topics such as diabetes and a series of bulletins summarising what is known about the effectiveness of interventions for particular conditions.

On the subject of research into the needs of elderly people, I can reassure the noble Viscount, Lord Falkland, that one of the members of the central committee, Professor Kay-Tee Khaw, is a professor of clinical gerontology with expertise in the interface between basic research and community based epidemiological studies. The elderly are an important client group in that respect.

The noble Lord, Lord Walton, referred to the adequacy of the service increment for teaching and research (SIFTR). Again, the department is undertaking a review of SIFTR. The steering group on undergraduate medical and dental education and research chaired by the Permanent Secretary of the department is taking a close continuing interest in that. The noble Lord, Lord Walton, also asked about the impact of changes in dual support on charities. We have tried to make it clear that dual support transfer is not intended to alter the basis on which charities commission their research in higher education institutes. The Government do not wish to see any reduction in the present level of public funding to underpin research projects sponsored by charities. I know the UFC is currently considering transitional arrangements to avoid any problems.

The noble Baroness, Lady McFarlane of Llandaff, spoke about multi-disciplinary research and in particular nursing research. I can reassure her that multi-disciplinary research will be actively promoted within the National Health Service R&D strategy. I understand that two members of the central committee are nurses and a group is now being established to develop a strategy for nursing research which will create a profession which can articulate the need for research, participate in carrying it out, and use research results to change practice. Members of the group will include both members of the central committee who have a nursing background and others with expertise in nursing and midwifery research, social policy and health services research and National Health Service management. It is intended that the strategy will be endorsed by the chief nursing officer, the director of research and development and by the nursing, midwifery and health visitor professions.

The noble Lord, Lord Butterfield, made a number of interesting points and mentioned specifically careers for researchers. In departmental terms, that is a matter for the Department of Education and Science and for the research councils. However, we are asking
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the regional health authorities to let us have their views about the provision of researchers as part of their R&D plans.

The matter of training was also referred to, particularly training in community care. The Government recognise the importance of training in improving the quality of social services for older people, children at risk and families caring for dependent relatives. We are providing funds for training. This year, 1992–93, the funds amount to some £56 million. Those funds are intended to ensure that all social services staff are equipped for their new task bearing in mind the terms of the Children Act and the community care aspect of our reforms.

I have perhaps taken a good deal of time to recount the background of the developments of the new system of National Health Service research and development strategy. However, the success of this strategy will lie not in any systems and structures which it engenders but rather in the development of an evaluative culture. In saying that, I echo the opening remarks of the noble Lord, Lord Hunter. We need to encourage managers, clinicians and everyone else concerned to identify the areas in which R&D can help them to deliver a better service. We need to help them to recognise the importance of asking the right questions so that the answers can be really useful to them. We need to ensure National Health Service ownership of the strategy so that more valuable research and development results are translated into action. Ultimately the success of the strategy will lie in the improvement of the health of the population. I am confident that this strategy will achieve those wider aims.

My Lords, I only have time to express my thanks in three respects. First, I thank the Minister for giving us a remarkable account in a relatively short time. She has encouraged every one of us here, as well as many people in the health service, and also someone who is sitting behind me at the Bar, to get on with this matter. Secondly, the right reverend Prelate the Bishop of Norwich has earned a place in this House as he has established himself as an authority in a special and important field. I am sure everyone in the House would wish to encourage him to keep on advising us and to keep us on course. Thirdly, I thank everyone who has taken part in this interesting debate. I beg leave to withdraw the Motion.